Outpatient / Endocrinology
Type 2 Diabetes
# Type 2 Diabetes
-- Last A1c *** on *** - at goal? *** (Goal A1c <7% or <8-8.5% if significant comorbidities or life expectancy <10 years; if <6.5% can back off on some treatments)
-- Issues with regimen: *** (compliance, access, side-effects)
-- Complications: *** (neuropathy, retinopathy, LE ulcers, CKD, gastroparesis)
-- Co-morbidities: *** (HTN, HF, HLD, CKD, Obesity, smoking)
Plan:
-- Weight/Nutrition/Exercise: *** goal >5% weight loss if BMI >25; aerobic exercise >3 days/week; cut back on refined sugars and grains
-- Oral Agents: *** metformin if A1c >6.5%, next agent if ASCVD high, A1c target not met, or A1c >8.5% at diagnosis
- Metformin 500-1000mg BID (1-2% A1c) - uptitrate 250-500mg per week
- GLP-1 Agonists - semaglutide 0.25-1mg qweek - uptitrate monthly
- SGLT-2 Inhibitors - empagliflozin 10mg daily - uptitrate monthly
-- Insulin: *** If A1c >9% or on two agents and A1c >8%
- Basal - start 0.1-0.2U/kg/day OR 10U/day of glargine or determir qhs; increase 2-4units q3 days until AM fasting BG is 80-130
- Prandial - if not at goal with basal 0.5U/kg/day; 4U or 0.1U/kg or 10% basal before largest meal then increase 1-2 units q3 days until 1-2h post-prandial level is <180; if A1c still not controlled, add to another meal and titrate
-- Lipids: *** (mod-intensity statin age 40-75 - atorva 10-20, rosuva 5-10, simva 20-40, prava 40-80, lova 40; high-intensity if CVD, risk factors, LDL>190, ASCVD >20% - atova 40-80, rosuva 20-40)
-- Co-Morbidity Tx: *** (ACE/ARB for HTN goal <140/90 or CKD with proteinuria or GFR <60)
-- Neuropathy: *** amitriptyline 10-150mg qhs, pregabalin (Lyrica) 150-300mg BID, gabapentin (Neurontin) 300mg-1200mg TID, duloxetine (Cymbalta) 60-120mg daily, venlafaxine 150-225mg; can also trial lidocaine patch or capsaicin cream
-- Screening: *** Foot exam, Annual Vision Exam (q2-3 if normal)
-- Monitoring: *** A1c q6 if controlled, q3 if not controlled; annual BMP and urine albumin/creatinine ratio
-- Refer: for ABI/vascular if concern for PVD; Renal if GFR <30
Template Coming Soon!
Pharmacology of Diabetes (Non-Insulin Agents)
Patient Guidance and Information
Prediabetes
Your A1c (a measure of your 3 month sugar average) puts you in the borderline diabetes range, or what we call "prediabetes." A "normal" a1c is 5.6% or less, prediabetes is 5.7 to 6.4%, and diabetes starts at 6.5%. This means that you are at increased risk for developing diabetes.
You can prevent diabetes by cutting calories, especially from sweets, starches (pastas, white rice, potatoes, bread), and sweetened beverages (sodas and juices); getting more exercise (20-30 minutes 3-4 times per week at least); and losing a few pounds.
We should plan to repear your A1c in *** months.
Diabetic Foot Recommendations
We would like you to perform daily foot examinations to assess for any ulcers (including between your toes) and any notable loss of sensation.
Please inspect daily, wash and dry daily, moisterize daily, wear loose fitting socks, trim nails straight across, never go barefoot, avoid high heels and open toed shoes, look inside shoes before putting them on.
If You Remember Nothing Else
Type 2 Diabetes is a complex metabolic syndrome caused by chronically elevated blood glucose levels. Over time, diabetes can lead to damage to the vasculature via nonenzymatic glycation which can lead to retinopathy, CKD, PAD, and heart disease. Diagnose prediabetes when A1c is 5.7-6.4% and diabetes when the A1c is 6.5% or greater. Begin by promoting lifestyle changes including cutting back on sugary drinks like sodas and juices. If prediabetes or just over 6.5%, give the patient 6 months to see if lifestyle changes can bring their levels down. If not, get baseline BMP (creatinine) and urine albumin/creatinine ratio and start the patient on metformin or a GLP-1 agonist. The ACCORD trial showed that targeting A1c 7-7.9 in those with co-morbidities was better than A1c goal <6. However, in otherwise younger or healthier patients, the goal should be to reverse diabetes and get A1c to normal levels. If A1c target not met, or is >8.5% at diagnosis at a second agent, commonly SGLT2 inhibitors, GLP-1 agonists. If A1c >9% on diagnosis, or on two agents with A1c >8%, you should start on insulin. Start with basal insulin, then add prandial one meal at a time with goal AM glucose 80-130 and 1-2 hour post-prandial glucose <180. All patients with diabetes get a statin, with intensity based on risk factors. ACE/ARB is first line for HTN and CKD in patients with diabetes. Patients should also be screened via frequent foot exams and q2-3 year vision exams.
Clinical Pearls
- 10.5% of U.S adults have T2DM (34 million, 7.3 million undiagnosed)
- Screen with A1c >45 years old or BMI >25 and risk factor (1st degree relative, nonwhite, HTN, HLD, sedentary, etc); then screen q3 years if normal
- Diagnosis if A1c >6.5%; glucose fasting >126, random >200
- Diabetes Exam includes foot exam (ulcers, pulses, hair findings, nail upkeep, sensation via monofilament until bends of 1st, 3rd, 5th toes), neuropathy, and vision
- In general, each oral monotherapy will lower A1c ~1% (0.7-1%)
- If at diagnosis A1c >10%, or quickly going up can consider going right to insulin (2 orals will likely not be able to get A1c down 3%+ in a timely manner)
- A1c can be artificially lower in patients with high RBC turnover (like sickle cell) - paper
- Treatment is now more about just lowering A1c - with new treatments should also be aware of CKD, HF, ASCVD risk factors - often treating those regardless of A1c level
- Don’t combine GLP-1 and DPP4 or sulfonylureas and insulin (think about the mechanisms of the drugs you are prescribing and why they work)
- If on insulin, make sure patients are aware of the signs/symptoms of hypoglycemia and what they should do in that circumstance
- If LFTs elevated, can consider NASH
- Acanthosis Nigricans is a possible cutaneous sign of insulin-resistance
- Damage of high glucose in vessels comes from nonenzymatic glycation - thickening of the basement membrane, retinopathy, etc.
- MI is the most common cause of death in diabetes patients
- Osmotic Damage (sorbitol accumulation) leads to neuropathy and cataracts
- Diabetic Nephropathy - nodular glomerulosclerosis (Kimmelstiel-Wilson nodules), progressive proteinuria
- Exogenous insulin use lacks C-peptide
Insulin Supplies
- Needles - 32G 4mm
- Syringes - come in boxes of 100 - for long-acting lasts 3 months, for basal/bolus need 4 boxes to last 3 months; choose the smallest barrel that can hold the dose (3/10mL if <30Units, 1/2mL 31-50, 1mL for 51-100)
- Alcohol Swabs - can be replaced with soap and water
- Test Strips - most boxes come with 50-100 strips, many choices - go with one covered by insurance
- Glucometer - go with whatever insurance will cover
Trials and Literature
- Classification and Diagnosis of Diabetes 2021
- Pharmacological Approaches to Diabetes 2021
- ACCORD Trial - Effects of Intensive Glucose Lowering in T2DM (NEJM 2018) - Higher mortality in intensive therapy A1c <6 vs A1c 7-8; no sig difference in composite endpoint MI, stroke, death; more likely to have hypoglycemia and weight gain in the intensive therapy group
- UKPDS: Reducing Diabetes-Related Morbidity and Mortality - 2 Min Medicine; BG control reduces the risk of microvascular complications but not macrovascular; Metformin reduces all-cause mortality, is considered first line; The strict control of BP in T2DM reduced risk of micro and macrovascular complications
- CREDENCE Trial - Canagliflozin to Prevent CV and Renal Disease (NEJM 2019)
- EMPA-REG OUTCOME - empagliflozin CV Outcome in T2DM
- Meta-Analysis of SGLT2i with Cardiovascular and Kidney Outcomes in T2DM - JAMA
- RENAAL Trial - Losartan in Diabetic Nephropathy - 2 Min Medicine; Losartan 50 daily reduced risk of developing ESRD, but NOT mortality
- Treating Painful Diabetic Periheral Neuropathy - (AFP, 2016)
Other Resources
- Curbsiders - Diabetes Triple Distilled (2020); Diabetes FAQ (2021); Diabetic Feet
- Core EM/IM - Core IM Diabetes
- Run the List - T2DM Outpatient Handout
- The Diabetes Code - Book by Dr. Jason Fung
Tweetorials
Video
